HomeMy WebLinkAboutDeficiency Form (20) ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type o F ity: Date Visit:
Kidz Cam Day
1� Night ❑❑ /�/ ��
Both ❑ month/ day / year
Facility Address: 1256 HWY 43 Telephone#:
Killen, AL 35645 (256) 272-5060
Ages: ! Staff in Charge(rf applicable): Capacity:
f
6 wks-14 yrs / X Amanda Robertson
da I / night 46 / X
day / night
SECTION B-DEFICIENCY INFORMATION
Column 11 Column 2
Health&Safety Guidelines Date Corrected
Deficiency
l )
1
VSfl 4A bra
6
INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by the facility representative after each
deficiency is corrected The facility representative must put the orrec' and his/her initials in Column 2. This form must be
returned to the Department of Human Resources on or before 1.1 Z42J as verification that deficiencies have been
correcte I
*Hazards must be corrected immediately
I
NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to correct the listed deficiencies can
be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of Health &
Safe�Guidelines. A facility approved by the Department must meet Health&Health&Safe�Guidelines applicable to that facility at all times.
It is the responsibility of the facility to operate in complianceth Health&Safe�Guidelines.
Signature of Facility Representative Date I-JA-21
Signature of DHR Represe Date
I
COPIES TO:Amanda Robertson Page `of